The nurse caring for the client diagnosed with sickle cell crisis places priority on which specific goal(s) prior to discharge? (SELECT ALL THAT APPLY)

Decrease fluid intake of 1000 mL/day to prevent fluid overload

The client verbalizes the procedure for a 24-hour urine collection

Oxygenation and perfusion to meet cellular and metabolic needs

Complications are prevented or minimized

Pain is relieved or controlled

Answer and Explanation

Correct Answer : C,D,E

A. Decrease fluid intake of 1000 mL/day to prevent fluid overload: This goal is not appropriate. Clients with sickle cell crisis often require increased fluid intake to prevent dehydration and promote circulation, so limiting fluids is counterproductive.

B. The client verbalizes the procedure for a 24-hour urine collection: While understanding this procedure may be relevant for monitoring kidney function or hydration status, it is not a priority goal directly related to managing sickle cell crisis.
C. Oxygenation and perfusion to meet cellular and metabolic needs: Ensuring adequate oxygenation and perfusion is crucial in managing sickle cell crisis, as compromised blood flow can exacerbate pain and lead to further complications.

D. Complications are prevented or minimized: Preventing complications, such as infections or acute chest syndrome, is a key goal in managing a client with sickle cell disease, making this a critical aspect of discharge planning.

E. Pain is relieved or controlled: Pain management is a primary focus during a sickle cell crisis. Ensuring that pain is effectively managed before discharge is essential for the client's comfort and overall well-being.

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Correct Answer is C

Explanation

A. "The chest pains caused by a spasm of my heart": This statement reflects a misunderstanding. Chronic stable angina is typically caused by myocardial ischemia due to atherosclerosis rather than spasms. While vasospasm can occur, it is not the primary cause of chronic stable angina.

B. "I should not experience chest pain since I am on aspirin therapy": This statement is misleading. Aspirin therapy helps reduce the risk of clot formation and subsequent heart attacks but does not eliminate angina. Patients may still experience angina symptoms during exertion or stress.

C. "I should hire someone to shovel snow in the winter": This statement indicates an understanding of the need to avoid excessive physical exertion that could trigger angina. Hiring someone to perform strenuous tasks like shoveling snow reflects a proactive approach to managing the condition and preventing potential angina episodes.

D. "Each time I have chest pain my heart is damaged more": This statement is overly alarmist. While recurrent angina can indicate underlying heart issues, occasional episodes of stable angina do not necessarily result in immediate, progressive heart damage.

A. 2 inches 21 gauge B. 1 1/2 inch 27 gauge C. 5/8 inch 25 gauge D. 1/4 inch 19 gauge

Correct Answer is C

Explanation

A. 2 inches 21 gauge: This option is too long and too large in gauge for subcutaneous administration. Typically, a longer needle is not necessary for subcutaneous injections, especially for standard adult adipose tissue.

B. 1 1/2 inch 27 gauge: While this gauge is acceptable, the length is still longer than typically required for subcutaneous injections. A 1 1/2 inch needle is more suited for intramuscular injections.

C. 5/8 inch 25 gauge: This is the most appropriate choice for a subcutaneous injection. A 5/8 inch needle is typically adequate for subcutaneous tissue in adults, and a 25 gauge needle provides a suitable size for comfort while allowing the medication to be administered effectively.

D. 1/4 inch 19 gauge: This option is not suitable for subcutaneous injections. A 1/4 inch length is too short for effective penetration into subcutaneous tissue, and a 19 gauge needle is larger than necessary, which could increase discomfort.

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The nurse caring for the client diagnosed with sickle cell crisis places priority on which specific goal(s) prior to discharge? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has chronic stable angina is being discharged. Which statement by the client indicates an understanding of the discharge teaching?

Correct Answer is C

Explanation

The nurse calculates that 0.74 mi of filgrastim must be administered to a client subcutaneously. The client weights 165 lbs. What length and gauge of needle is best to administer this medication?

Correct Answer is C

Explanation

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